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NC STATE BOARD OF ELECTIONS State Absentee Ballot Request Form P. O. BOX 27255 RALEIGH, NC 27611-7255 North Carolina Franklin County PHONE: 1-866-522-4723 FAX: 919-715-0135 [email protected]

General Instructions A person must be a registered voter in their North Carolina county of residence in order to request an absentee ballot. If not registered to vote in the proper county, a person must submit a voter registration application along with this form. Voter registration applications are available online at www.ncsbe.gov. The deadline to register to vote is 25 days prior to the date of the election.

Completing the Form The voter’s full name, residential address, date of birth and an identification number (see Proof of Identification below) must be provided on this form. This information will be used to confirm your voter registration. In addition, this form must be signed by the voter or the voter’s near relative or qualified legal guardian.

Who may make a request for an absentee ballot Either the voter or the voter’s near relative or qualified legal guardian may request an absentee ballot. A “near relative” is defined as the voter’s spouse, brother, sister, parent, grandparent, child, grandchild, mother-in-law, father- in-law, daughter-in-law, son-in-law, stepparent, or stepchild.

Who may not make a request for an absentee ballot If a registered voter is a patient in any hospital, clinic, nursing home or rest home in this State, it is unlawful for any owner, manager, director, employee, or other person, other than the voter's near relative or verifiable legal guardian, to request an absentee ballot on behalf of the voter. The voter’s county board of elections should be contacted if a voter in a hospital, clinic, nursing home or rest home in this State needs assistance requesting or voting an absentee ballot.

Updating Voter Information This form may also serve as a voter change form; however, changes in voter registration may only be made by the voter.

Proof of Identification If the voter’s identification number (NC driver license number, NC DMV-issued identification card number, or last four digits of social security number) is not provided, then provide with this request a copy of a document that shows the name and residential address of the voter: a current utility bill, bank statement, government check, paycheck, or other government document.

Ballot Availability Absentee balloting materials are mailed to voters once ballots for an election are available. For most elections, ballots will be available 50 days prior to the date of the election. Absentee ballots are available 60 days prior to the date of a statewide general election and 30 days prior to the date of a city or municipal election.

Submitting the form Submit this form to the Franklin County Board of Elections no later than 5:00 p.m. on the Tuesday before the date of the election.

Address PO BOX 180 107 Industrial Drive Louisburg, NC 27549 919-496-3898 Email: [email protected] Fax 919-496-7418 TO Franklin County Board of Elections State Absentee Ballot Request Form : PO Box 180 Louisburg, NC 27549 North Carolina PHONE: 919-496-3898 FAX: 919-496-7418 [email protected]

FRAUDULENTLY OR FALSELY COMPLETING THIS FORM IS A CLASS I FELONY UNDER CHAPTER 163 OF THE NC GENERAL STATUTES.

I am requesting an absentee ballot for the: on . Election Type (Primary, General, Municipal, Special, etc.) Election Date Voter Information Last Name First Name Middle Name Suffix Date of Birth Required

Home Address (NC Residential Address.) Mailing Address (If different than home address.)

City State Zip Code City State Zip Code

Have you lived at this address for more than 30 days? Yes No County of Residence Previous Name (if applicable)

If “No,” indicate the date of your move: _____ /_____ / _____ You must provide at least one identification number below. (or see instructions) Voter Registration No. Phone Email NC License or ID Number SSN Optional Optional Optional X X X - X X -

Absentee Voting Information Absentee Mailing Address (Where should the ballot be mailed?) City State Zip Code

If voter is registered as Unaffiliated and requesting a ballot for a partisan primary, choose a primary ballot preference. Democratic Republican Libertarian Non-partisan

If voter is a patient in a hospital, clinic, nursing home or rest home, please indicate whether you will need assistance in marking your ballot. Yes No

If “Yes,” what is the name and address of the hospital or facility: If requesting an absentee ballot on behalf of a near relative, list your name, address, contact information and relationship to the voter: Requestor’s Name spouse brother /sister parent grandparent stepparent child grandchild stepchild mother-in-law father-in-law son-in-law daughter-in-law legal guardian

(First) (Middle) (Last) (Suffix) Requestor’s Address Name of Corporation (If appointed legal guardian)

City State Zip Code Requestor’s Phone Requestor’s Email

For Military/Overseas Citizens Only (may only be signed by the voter; may not be signed by a near relative/guardian) Select one of the options below to qualify as a military or overseas voter: Member of the Uniformed Services or Merchant Marine on active duty and currently absent from county of residence or an eligible spouse/dependent.

U.S. citizen residing outside the U.S. temporarily or indefinitely Current Address (Address where you are currently stationed or living overseas.) Transmit my ballot by: Mail Fax Email (Military/Overseas Voters Only) Fax Number or Email Address Signature of Voter (voter only) OR Signature of Near Relative/Legal Guardian (if applicable) X X Date Date

Visit www.NCSBE.gov to check your voter registration or absentee voting status. V2015.01